Anticoag Transitions 2016 PDF

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Transition of Anticoagulants 2016 Van Hellerslia, PharmD, BCPS, CACP, Clinical Assistant Professor of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA Pallav Mehta, MD, Assistant Professor of Medicine, Division of Hematology/Oncology, MD Anderson Cancer Center at Cooper Reviewer: Kelly Rudd, PharmD, BCPS, CACP, Clinical Specialist, Anticoagulation, Bassett Medical Center, Cooperstown, New York

From Apixaban

Apixaban

To Argatroban/ Bivalirudin/ Enoxaparin/ Dalteparin/ Fondaparinux/ Heparin Warfarin

Brand

Generic

Angiomax Arixtra Coumadin Eliquis Fragmin Lovenox Pradaxa Savaysa Xarelto

bivalirudin fondaparinux warfarin apixaban dalteparin enoxaparin dabigatran edoxaban rivaroxaban

Action Wait 12 hours after last dose of apixaban to initiate parenteral anticoagulant. In cases of high bleeding risk, consider omitting initial bolus when transitioning to heparin infusion.

When going from apixaban to warfarin, consider the use of parenteral anticoagulation as a bridge (eg, start heparin infusion/enoxaparin and warfarin 12 hours after last dose of apixaban and discontinue parenteral anticoagulant when INR is therapeutic ≥2). Wait 12 hours from last dose of apixaban to initiate dabigatran, edoxaban, or rivaroxaban.

Apixaban

Dabigatran, Edoxaban, or Rivaroxaban

Argatroban

Apixaban, Dabigatran, Edoxaban, or Rivaroxaban

Start apixaban, dabigatran, edoxaban, or rivaroxaban within 2 hours of stopping argatroban.

Argatroban

Enoxaparin/ Dalteparin/ Fondaparinux/ Heparin

If no hepatic insufficiency, start parenteral anticoagulant within 2 hours of stopping argatroban. If there is hepatic insufficiency, start parenteral anticoagulant after 2-4 hours of stopping argatroban.

Argatroban

Warfarin

*The use of enoxaparin/dalteparin/heparin assumes the patient does not have heparin allergy or heparin-induced thrombocytopenia. Argatroban must be continued when warfarin is initiated and co-administration should continue for at least 5 days. Argatroban elevates the INR. After 3-5 days of co-therapy with warfarin, and if the INR is >4.0, temporarily suspend the argatroban for 4 hours, then check the INR. If the INR is 3.0, consider warfarin dose adjustment. Argatroban may need to be restarted if warfarin-argatroban overlap has not been prescribed for 5 days

Bivalirudin

Argatroban/ Dalteparin/ Enoxaparin/ Fondaparinux/ Heparin

Initiate parenteral anticoagulant within 2 hours after discontinuation of bivalirudin. *The use of heparin/dalteparin/enoxaparin assumes the patient does not have heparin allergy or heparin-induced thrombocytopenia. In cases of high bleeding risk, consider omitting initial bolus when transitioning to heparin infusion.

Bivalirudin

Bivalirudin

Apixaban/ Dabigatran/ Edoxaban/ Ravaroxaban Warfarin

Initiate apixaban, dabigatran, edoxaban, or rivaroxaban within 2 hours after discontinuation of bivalirudin.

Bivalirudin must be continued when warfarin is initiated and co-administration should continue for at least 5 days. Bivalirudin elevates the INR. After 3-5 days of co-therapy with warfarin, temporarily suspend the bivalirudin for 4 hours, then check the INR. If the INR is 3.0, consider warfarin dose adjustment. Bivalirudin may need to be restarted if warfarin-bivalirudin overlap has not been prescribed for 5 days.

Dabigatran

Dabigatran

Dabigatran

Argatroban/ Bivalirudin/ Enoxaparin/ Dalteparin/ Fondaparinux/ Heparin Apixaban, Edoxaban, or Rivaroxaban

If CrCl >30 mL/min, wait 12 hours after last dose of dabigatran to initiate parenteral anticoagulant. If CrCl 30 mL/min, wait 12 hours after last dose of dabigatran to initiate apixaban, edoxaban, or rivaroxaban. If CrCl...